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Get and Sign Consultation a Woman's TimeA Woman's Time Form

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Have patient bring a list of current medications. Address Phone Number Fax This appointment is being requested for my patient for the following reason Consultation treatment if needed with Dr. Failure to return the completed form and records may result in delay in scheduling the patient s appointment Please file completed form in patient s chart 50. Signature of Requesting Physician Note Please fax this completed form copy of insurance card pertinent progress notes labs and x-rays to our office...
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